Vaccines are one of the greatest accomplishments in the history of public health because of their ability to promote and maintain population health (Edwards, Hackell, Committee on Infectious Diseases & Committee on Practice and Ambulatory Medicine, 2016). Vaccines are a primary method of prevention that works by introducing the body to disease antigens (Zelman, Raymond, Dafnis, & Mulvihill, 2015). The antigens cause an immune response that allows people to build immunity without ever being infected (Zelman et al., 2015). Although vaccines have been around since the 1800s, 1.4 million children around the world die from vaccine-preventable diseases (VPD) every year (Zelman et al., 2015). Vaccine protection is dependent on herd immunity (Edwards et al., 2016). Enough people must be vaccinated to protect themselves, children, and other vulnerable populations who cannot or have not been vaccinated (Edwards et al., 2016). Vaccine confidence changes over time and some adults decide to not vaccinate themselves or their children (Edwards et al., 2016). We are reminded of the dangers of VPD in the United States when measles outbreaks occur like the one in Anaheim, California (Buttenheim, Jones, Mckown, Salmon & Omer, 2018). This paper will discuss the decreases in childhood immunization rates, increases in vaccine exemption rates, and potential solutions for vaccine hesitancy in the United States.
The United States has maintained high immunization levels because schools require certain immunizations for children to be enrolled in public schools (Edwards et al., 2016). Most states require vaccines for the following conditions prior to enrollment: diphtheria, tetanus, and pertussis (DTaP); measles, mumps, and rubella (MMR); and varicella (Mellerson et al., 2018). The immunization rate of kindergartners who enroll in public schools is an important indicator of vaccine confidence because it is widely reported by all states (Mellerson et al., 2018). In the 2017-2018 academic year, incoming kindergartners achieved 95.1% DTaP, 94.3% 2-dose MMR, and 93.8% varicella median vaccination coverage (Mellerson et al., 2018). Childhood immunization rates change over time because of changes in disease incidence and disease outbreaks (Edwards et al., 2016). Before a vaccine is created, vaccine coverage is zero, and disease incidence is high (Edwards et al., 2016). After a vaccine has been developed, people get vaccinated and disease incidence decreases (Edwards et al., 2016). Public trust in the vaccine will eventually peak and an outbreak will occur as vaccination coverage drops below ideal rates (Edwards et al., 2016). Outbreaks tend to cause immunization rates to increase again after being exposed to VPDs (Edwards et al., 2016). A recent example is the Disneyland measles epidemic in Anaheim, CA caused by a 50-85% vaccination rate (Olive, Hotez, Damania & Nolan, 2018). Currently, US schools are seeing increases in enrolled kindergartners with exemptions for some or all required vaccines (Edwards et al., 2016). Decreasing trends in vaccination are not a new phenomenon, but it is more dangerous than ever because modern transportation makes the spread of vaccine-preventable diseases easier than ever before (Edwards et al., 2016).
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Vaccine exemptions have been increasing for the last three school years nationwide (Mellerson et al., 2018). Parents can excuse their children from all or individual immunization requirements by filing for a medical exemption or a nonmedical exemption (NME) (Olive et al., 2018). All states allow medical exemptions for children who are too young, immunosuppressed, allergic to vaccine ingredients, or who have had a bad reaction (Edwards et al., 2018). NMEs can be approved for religious or philosophical beliefs (Edwards et al., 2018). According to researchers, “Since 2009, the number of “philosophical-belief” vaccine nonmedical exemptions (NMEs) has risen in 12 of the 18 states that currently allow this policy (Olive et al., 2018, para. 8).” The American Academy of Pediatrics proposed legislative changes to stop all exemptions NMEs in children (Edwards et al., 2016). California, Mississippi, and West Virginia only allow medical exemptions (Edwards et al., 2016). In the 2016-2017 school year, vaccine exemptions ranged from 0.1% in Mississippi to 7.6% in Oregon (Mellerson et al., 2018). During the same period, 0.2% of kindergarteners had a medical exemption and 2.0% had an NME (Mellerson et al., 2018). Twenty-nine states experienced an increase in exemptions during the following school year (Mellerson et al., 2018). State NME rates for kindergartners can conceal higher county-level NME rates (Olive et al., 2018). For example, Idaho’s state NME rate was 6.2% during the 2016-2017 year (Olive et al., 2018). The three highest county NME rates in Idaho were 26.67% in Camas County, 19.65% in Bonner County, and 18.18% in Valley County (Olive et al., 2018). Rates this low can jeopardize the health of children and adults who cannot get vaccinated (Olive et al., 2018). VPDs require different rates of vaccination coverage to achieve adequate herd immunity (Orenstein & Ahmed, 2017). For example, measles requires a 92-94% immunization rate while rubella only requires 83-85% (Orenstein & Ahmed, 2017). Researchers have discovered a correlation between high NME rates and low MMR vaccination coverage (Constable, Blank & Caplan, 2014). Nonmedical exemptions are often criticized because of how simple the application process can be (Constable et al., 2014). Some states have imposed new laws that require a doctor’s signature to ensure parents receive factual educational materials related to childhood immunizations (Constable et al., 2014).
Physicians have observed an increase in parents displaying vaccine hesitancy and resistance (Edwards et al., 2016). Vaccine hesitancy describes the spectrum of parental opinions that range from vaccine advocates to absolute vaccine refusers (Edwards et al., 2016). The opinion of parents matters because they legally have the power to make medical decisions for their children (Vaughn, 2017). They decide whether their children get vaccinated. Parents report feeling hesitant because of the potential for injection site pain (44%), perceived risk of too many vaccines (34%), risk of autism (26%), and lack of safety testing (13.2%) (Edwards et al., 2016). Pediatricians and family medicine doctors have an influential role in achieving parental consent for vaccination because they can address parental apprehensions and elaborate on the benefits of vaccines (Edwards et al., 2016). 80% of parents said their child’s physician played an influential role in their decision-making process. To address parental concerns doctors can distract the child by talking to them or vaccinating them after breastfeeding when the child is sleepy (Edwards et al., 2016). Physicians can also use numbing cream for pain or give the most painful vaccine last (Edwards et al., 2016). Educating hesitant parents about the risks and benefits can minimize perceived health risks by promoting the evidence-based benefits of vaccination (Edwards et al., 2016).
Vaccination effectively maintains and protects population health only if enough people are immunized (Edwards et al., 2016). In the US there is an increasing trend of parents exempting their children from immunizations, despite the availability of highly effective vaccines for a variety of infectious diseases. As a result, vulnerable medical populations who cannot get vaccinated are at risk (Olive et al., 2018). Pediatricians are in a special position to inform parents experiencing vaccine hesitancy about the benefits of vaccination (Edwards et al., 2016). States have started to review and consider changing the application process for nonmedical exemptions due to recent events caused by low immunization coverage, such as the nationwide measles outbreaks that started in Anaheim, California (Buttenheim et al., 2018). In future years, state governments will either make it more difficult to obtain personal belief nonmedical exemptions or ban them altogether (Pottinger, Jacobs, Haenchen & Ernst, 2018). Religious nonmedical exemptions will most likely continue to be respected because religion is protected as a part of the first amendment of the Constitution.
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